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11 Meghan Ames Mrs. Matuszak KNH 406 March 18, 2010 Diabetes Case Study #4 Understanding the Disease and Pathophysiology 1) Define insulin. Describe its major functions within normal metabolism. Insulin is a hormone produced in the β cells of the pancreas. It is responsible for facilitating the movement of glucose from the blood into the body s muscle and fat cells. It is secreted in response to an increase in blood glucose. 2) What are the current opinions regarding the etiology of type 1 diabetes mellitus (DM)? Type 1 DM results from the autoimmune destruction of pancreatic cells preventing the synthesis and secretion of insulin. The trigger for autoimmune destruction is debated and hypotheses include environmental toxins or infections 3) What genes have been identified that indicate susceptibility to type 1 diabetes mellitus? Genes that influence the function of pancreatic β cells have been examined for possible links to T1DM. Additionally, genes related to functions influencing metabolic syndrome are being reviewed for a link to T2DM. For example, PPARγ is being reviewed for its possible role in insulin resistance. 4) After examining Susan s medical history, can you identify any risk factors for type 1 DM? Susan has a family hx of DM which is a risk factor in her development of the disease consider the potential genetic links of the disease. 5) What are the established diagnostic criteria for type 1 DM? How can the physicians distinguish between type 1 and type 2 DM? DM is usually diagnosed through an oral glucose tolerance test. T1DM can be diagnosed in individuals with a plasma glucose 200 mg/dl or a fasting plasma glucose 126 mg/dl when presented with additional symptoms, such as unexplained weight loss, pollydipsia, or polyuria. One distinction helpful in the diagnosis of DM is that T1DM is illustrated by sudden onset of symptoms, where T2DM is more gradual. Additionally, T2DM is almost always seen in conjunction with symptoms of metabolic syndrome. 6) Describe the metabolic events that led to Susan s symptoms (polyuria, polydipsia, polyphagia, weight loss, and fatigue) and integrate these with the pathophysiology of the disease. Glycosuria and polyuria result from the excretion of excess blood glucose that has built up because of a lack of insulin in the body. This polyuria results in an excessive water loss, leading to polydipsia, polyphagia, and weight loss. Fatigue is a symptom of muscle and fat cells that are starved for energy due to inadequate insulin levels.

12 7) List the microvascular and neurologic complications associated with type 1 diabetes. Some of the long-term complications associated with T2DM include cardiovascular disease, nephropathy, retinopathy, peripheral neuropathy, and autonomic neuropathy. 8) When Susan s blood glucose level is tested at 2 am, she is hypoglycemic. In addition, her plasma ketones are elevated. When she is tested early in the morning before breakfast, she is hyperglycemic. Describe the dawn phenomenon. Is Susan likely to be experiencing this? How might this be prevented? The dawn phenomenon is an increased blood glucose in the early morning resulting from increased glucose production in the liver throughout an overnight fast. This can be mediated by administration of a combination of short- and intermediate-acting insulins before breakfast, short-acting insulin before evening meals, and intermediate-acting insulin at bedtime. 9) What precipitating factors may lead to the complication of diabetic ketoacidosis? List these factors and describe the metabolic events that result in the signs and symptoms associated with DKA. Omission or improper practice of insulin delivery, or general lack of blood glucose self monitoring can lead to DKA because blood glucose levels can sky-rocket, resulting in generation of ketones. Severe illness or infection can also impact a person s blood glucose and the amount of insulin needed. In addition, illness or emotional distress can vary an individual s eating patterns and throw off the balance between intake and insulin delivery. Nutrition Assessment Evaluation of Weight/Body Composition 10) Determine Susan s stature for age and weight for age percentiles. 62 = 1.65 m 25 th percentile CDC Stature-for-age percentiles: Girls, 2 to 20 years 100 # = 45.5 kg 20 th percentile CDC Weight-for-age percentiles: Girls, 2 to 20 years 11) Interpret these values using the appropriate growth chart. Stature and weight for age percentiles between the 10 th and 85 th percentile are considered normal. Considering this, Susan falls in a normal range according to the stature for age (25 th percentile) and weight for age (20 th percentile) growth curves. There is slight concern that Susan s weight may be a bit low for her stature considering the difference in these two percentiles. Calculation of Nutrient Requirements 12) Estimate Susan s daily energy and protein needs. Be sure to consider Susan s age. EER for Females 9 through 18 Years EER = (15) [10.0 (45.5) (1.65)] + 25 = 2313 kcal PA = active 2

13 13) What would the clinician monitor in order to determine whether or not the prescribed energy level is adequate? To monitor whether or not Susan is receiving adequate energy, her weight should be measured daily. Additional measures of her nutritional adequacy would include a lipid panel, albumin, and nitrogen balance. Intake Domain 14) Using a computer dietary analysis program or food composition table, calculate the kilocalories, protein, fat (saturated, polyunsaturated, and monounsaturated), carbohydrate, fiber, and cholesterol content of Susan s typical diet. 4,435 kcal 134 g. protein 167 g. fat (66 g. saturated, 32 g. polyunsaturated, 56 g. monounsaturated) 617 g. carbohydrate 25 g. fiber 324 mg. cholesterol *See attached FitDay nutrient analysis. 15) What dietary assessment tools can Susan use to coordinate her eating patterns with her insulin and physical activity? A diabetic exchange list is a relatively easy way to track the amount of carbohydrate Susan takes in and determine the appropriate amount of insulin to deliver. She can confirm this estimate by self-monitoring of blood glucose (SMBG) using a typical SMBG test such as a pin-prick and a reagent strip. Physical activity is an important aspect of Susan s T1DM treatment, and must be carefully monitored. Blood glucose levels should be taken both before and after exercise, and at times maybe during breaks in exercise to ensure that hyperglycemia and hypoglycemia to not develop as a result of the increased energy needs of Susan s skeletal muscles. 16) Dietitians must obtain and use information from all components of a nutrition assessment to develop appropriate interventions and goals that are achievable for the patient. This assessment is ongoing and continuously modified and updated throughout the nutrition therapy process. For each of the following components of an initial nutrition assessment, list at least three assessments you would perform for each component: Component Clinical data Nutrition history Weight history Physical activity history Assessments You Would Perform Fasting plasma glucose Plasma lipid profile Glycated hemoglobin assays Typical intakes of sugar Overall energy intake Profile of lipids consumed Current anthropometrics Acute changes in weight Weight for age percentile Typical daily activities 3

14 Monitoring Psychosocial/economic Knowledge and skills level Expectations and readiness to change Preferences of physical activity (ex: sports) Any cardiovascular risks of physical activity Monthly anthropometrics SMBG 3 times daily HbA 1C every 3 months Access to diabetic, low-sugar foods Access to diabetic testing materials Familial/social support of SMBG routine Knowledge of balanced diet Understanding of T1DM Ability to complete regular SMBG Attitude towards diagnosis Personal short- and long-term goals Desire to remain in compliance Clinical Domain 17) Does Susan have any laboratory results that support her diagnosis? One criteria for diagnosis of DM is a causal plasma glucose 200 mg/dl. Susan s glucose is 250 mg/dl, which supports this diagnosis. Additionally, Susan s glycated hemoglobin is also high (normal is % and recommendations for glycemic control are < 7.0%), which supports a diagnosis of DM. 18) Why did Dr. Green order a lipid profile? Although Susan does not exhibit typical risk factors for CVD, her diabetes can increase her risk for both macro- and microvascular complications that can be further exacerbated by dyslipidemia. Regular monitoring of plasma lipids is an important preventative approach for patients with DM. 19) Evaluate Susan s laboratory values: Chemistry Prealbumin (mg/dl) Osmolality (mmol/kg/h 2 O) Glucose (mg/dl) Normal Value Susan s Value Reason for Abnormality Hypovolemia resulting from polyuria Hypovolemia resulting from polyuria Inadequate insulin production BUN (mg/dl) Catabolism of protein due to cell starvation HbA 1C (%) Inadequate insulin production Nutritional Implications Rehydration and prevention of polyuria Rehydration and prevention of polyuria Regulation of glucose intake and insulin delivery Make energy available to cells Chronic hyperglycemia 4

15 20) Compare the pharmacological differences in insulins: Type of Insulin Brand Name Onset of Action Peak of Action Duration of Action Lispro Humalog min 1-3 hr 3-5 hr Aspart NovoLog min 1-3 hr 3-5 hr Glulisine Apidra min 1-3 hr 3-5 hr NPH Humulin N, 1-3 hr 8 hr 20 hr Novlin N Glargine Lantus 1 hr None 24 hr Detemir Levemir 1 hr None 24 hr 70/30 premix Mixtard, min Dual hr Humulin 70/30 50/50 premix Humulin 50/ min Dual hr 60/40 premix Mixtard min 2-8 hr 24 hr 21) Once Susan s blood glucose levels were under control, Dr. Green prescribed the following insulin regimen: 24 units of glargine in PM with the other 24 units as lispro divided between meals and snacks. How did Dr. Green arrive at this dosage? Dr. Green s insulin prescription is a flexible insulin therapy comprised of basal insulin once daily and multiple daily injections (MDIs) of bolus insulin before meals. Susan s daily basal insulin dose can be determined by multiplying her weight in kilograms by 0.6 units of insulin, yielding 27.3 units. Dr. Green suggested 24 units of basal insulin and approximately 24 units of bolus insulin depending on food intake. He selected a longacting basal insulin (glargine) to be delivered before bed and last through the night and a faster acting insulin (lispro) to be delivered throughout the day and as needed. Behavioral-Environmental Domain 22) Identify at least three specific potential nutrition problems within this domain that will need to be addressed for Susan and her family. Excessive energy intake (NI-1.5) RT polyphagia AEB dietary recall of 4,435 kcal (EER is 2313). Undesirable food choices (NB-1.7) RT inadequate knowledge of and/or disregard for nutritional guidelines AEB diet high in refined sugars and fats and low in nutrients. Irregular eating patterns (NB-1.5) RT busy volleyball schedule AEB pt. self-report. 23) Just before Susan is discharged, her mother asks you, My friend who owns a health food store told me that Susan should use stevia instead of artificial sweeteners or sugar. What do you think? What will you tell Susan and her mother? Stevia is a natural sweetener that can be used in place of sugar and other artificial sweeteners. Sweeteners alternative to sugar can be helpful tools for individuals with diabetes who are trying to manage their carbohydrate intake. Additional benefits of stevia (such as the delayed development of insulin resistance) are debated within the scientific community (Cheng, et. al., 2005). There also exist some support for detrimental impacts 5

16 of artificial sweeteners, but these adverse health effects are only seen in unreasonably high intakes of the products. In conclusion, there are a variety of sweetening alternatives, including stevia, acesulfame-k, sucarlose, etc., that are all safe for Susan to use depending on her personal preference. Nutritional Diagnosis 24) Select two high-priority nutrition problems and complete the PES statement for each. Impaired glucose utilization (NC-2.1) RT inadequate insulin synthesis by pancreas AEB hyperglycemia, FBG of 250 mg/dl and HbA 1C of 7.95%. Involuntary weight loss (NC-3.2) RT impaired glucose utilization AEB pt. self-report. Nutrition Intervention 25) For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). FBG < 200 mg/dl and HbA 1C < 7.0% to be achieved by SMBG and delivery of synthesized insulin. Return to UBW (as determined by pt.) to be achieved by improved glucose utilization by SMBG and delivery of synthesized insulin. 26) Does the current diet order meet Susan s overall nutritional needs? If yes, explain why it is appropriate. If no, what would you recommend? Justify your answer. Nutrient Grams Kilocalories % Intake AMDR Total energy NA 2, % 100% Carbohydrate 300 1,200 50% 45-65% Protein % 10-35% Lipid % 20-35% Susan s current diet order (2,400 kcal, 300 g CHO, g protein, 80g lipid) does meet all of her overall nutritional needs. Her total energy intake is within an acceptable range of her EER (2,313) and all of her macronutrients also fall with the AMDR. Nutrition Monitoring and Evaluation 27) Susan is discharged Friday morning. She and her family have received information on insulin administration, SMBG, urine ketones, recordkeeping, exercise, signs, symptoms, and Tx of hypo-/hyperglycemia, meal planning (CHO counting), and contraception. Susan and her parents verbalize understanding of the instructions and have no further questions at this time. They are instructed to return in 2 weeks for appointments with the outpatient dietitan and CDE. When you come in to work Monday morning, you see that Susan was admitted through the ER Saturday night with a BG of 50 mg/dl. You see her when you make rounds and review her chart. During an interview, Susan tells you she was invited to a party Saturday night after her discharge on Friday. She tested her blood glucose before going to the party, and it measured 95 mg/dl. She took 2 units of insulin and knew she needed to have a snack that contained approximately 15 grams of CHO, so 6

17 she drank one bee when she arrived at the party. She remembers getting lightheaded and then woke up in the ER. What happened to Susan physiologically? Susan suffered from acute severe hypoglycemia, resulting from her insulin injection. While Susan was correct in selecting one beer as an appropriate delivery of 15 g. of CHO, she was incorrect in selecting 15 g. of CHO as an appropriate delivery for 2 units of insulin. One unit of insulin should be delivered for each carbohydrate exchange (15 g. of CHO). Thus, Susan should have had a snack containing 30 g. of carbohydrate rather than 15 g. Her insulin dose was twice what she needed to take in her 15 g. of carbohydrate, sending her into a state of sever hypoglycemia, which resulted in her loss of consciousness. 28) What kind of educational information will you give her before this discharge? Keep in mind that she is underage for legal consumption of alcohol. At this point I would talk to Susan about her responsibility as a 15-year old to managing her own health. I would reiterate the exchange system and how it correlates with insulin doses and go over a few exercises with Susan to ensure that she understands the correct calculations. Secondly I would address with Susan some of the physiological effects of alcohol, discussing the importance of her abstaining from alcohol until her brain is fully developed (around age 21) as well as some of the legal ramifications that can result from underage drinking. 7

18 References Chang, J.-C., Wu, M. C., Liu, I.-M., & Cheng, J.-T. (2005, April). Increase of insulin sensitivity by stevioside in fructose-rich chow-fed rats. Hormone and Metabolic Research, 37(10), Retrieved March 28, 2010 from Nelms, M., Sucher, K., & Long, S. (2007). Nutrition and pathophysiology. Belmont, CA: Wadsworth. Rolfes, S. R., Pinna, K., & Whitney, E. (2009). Understanding normal and clinical nutrition (8 th ed.). Belmont, CA: Wadsworth. 8